System and method for treatment of upper airway disorders

ABSTRACT

The present invention provides a system for treating a mammalian patient having obstructive sleep disordered breathing, e.g., sleep apnea. The system has a set of appliances including a first appliance being adapted to displace a mandible of the patient by a first predetermined geometry relative to a maxilla of the patient. The set also includes at least a second appliance adapted to displace the mandible of the patient by a second predetermined geometry relative to the maxilla of the patient. In a specific embodiment, the first predetermined geometry is substantially different from the second predetermined geometry. Preferably, either one of the first appliance or at least the second appliance is worn by the patient based upon a predetermined treatment plan that includes one or more provisions for wearing at least the first and the second appliances.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent No.60/551,723 filed Mar. 10, 2004, commonly assigned, and herebyincorporated by reference for all purposes.

STATEMENT AS TO RIGHTS TO INVENTIONS MADE UNDER FEDERALLY SPONSOREDRESEARCH OR DEVELOPMENT

Not Applicable

REFERENCE TO A “SEQUENCE LISTING,” A TABLE, OR A COMPUTER PROGRAMLISTING APPENDIX SUBMITTED ON A COMPACT DISK

Not Applicable

BACKGROUND OF THE INVENTION

The present invention generally relates to ways of treating healthrelated disorders. More particularly, the invention provides a systemand method for treating certain types of breathing problems occurring ina mammal during sleep or other states of diminished consciousness.Merely by way of example, the invention is applied using a plurality oforal appliances for stepped treatment of obstructive sleep disorderedbreathing.

Many dentists employ oral appliances to treat various forms ofobstructive sleep disordered breathing (OSDB). In this context,Schmidt-Nowara et al al (Sleep. July 1995; 18(6):501-10.) define “oralappkiances” as a generic term of “devices inserted into the mouth inorder to modify the position of the mandible, the tongue, and otherstructures in the upper airway for the purpose of relieving snoring orsleep apnea.” Lowe (Pages 929-939 in: M H Kryger et al (eds). Principlesand Practice of Sleep Medicine. 3rd edition. Philadelphia: W. B.Saunders Company, 2000.) (Oral Maxillofacial Surg Clin N America.2002;14:305-317.) describes several commercially available oralappliances. These devices are generally worn by patients during sleep,and removed after awakening.

As implied by its name, obstructive sleep disordered breathing isgenerally associated with an obstruction to respiratory airflow duringsleep. Kuna and Remmers (Pages 840-858 in: M H Kryger et al (eds).Principles and Practice of Sleep Medicine. 3rd edition. Philadelphia: W.B. Saunders Company, 2000.) declare “The site of upper airwayobstruction lies in the pharynx,” which is a component of the upperairway. Ferguson (Clin Chest Medicine. 2003;24:355-364.) states that“Oral appliances may improve upper airway patency by enlarging the upperairway or decreasing upper airway collapsibility.” She further notesthat that simple active anterior movement of the tongue or mandible canincrease cross-sectional airway size. Lowe (Oral Maxillofacial Surg ClinN America. 2002;14:305-317.) notes that the tongue is attached to themandible and that devices that move the mandible anteriorly generallymove the tongue anteriorly as well. He discusses the therapeuticmechanism(s) of oral appliances: “Oral appliances . . . appear to workbecause of an increase in airway space, the provision of a stableanterior position of the mandible, advancement of the tongue or softpalate, and possibly by a change in genioglossus muscle activity.”Guilleminault and Quo (Dent Clin North Am. October 2001; 45(4):643-656.)note that different mechanisms may contribute in children: mandibularforward-repositioning functional appliances “achieve results on thecombined premise of growth adaptation and tooth movement.”

Ferguson (Clin Chest Medicine. 2003;24:355-364.) reviews several studiesof the effectiveness of oral appliance therapy for OSDB and concludesthey are effective in some patients with OSDB, particularly those withless severe OSA or simple snoring. She remarks that oral appliances arean appealing form of therapy for OSDB “because they are simple to use,reversible, and portable and generally have a low complication rate.”

According to Ferguson (Clin Chest Medicine. 2003;24:355-364.) the twomajor types of oral appliances used in treating OSDB are tonguerepositioning devices and mandibular repositioning appliances (MRAs).Schmidt-Nowara et al (supra.) state that “all oral appliances producedownward rotation of the mandible to varying extent; many also advancethe mandible by design.”

Ivanhoe and Attanasio (Dent Clin North Am. October 2001;45(4):733-58.)report evidence that a compromised airway, as may be encountered inOSDB, “can be almost completely restored” by moving the mandible forwardto 100% of its protrusive capability. On the other hand, they alsoreport that positioning the mandible at 100% of its protrusivecapability is “not an acceptable position for most patients because itis generally uncomfortable to maintain through the entire course ofsleeping.”

From this, one might conclude, as a rule of thumb, the greater thedegree of mandibular advancement conferred by an MRA, the more effectiveit is in treating OSDB, all other factors being equal. As a further ruleof thumb, however, the greater the degree of mandibular advancement, thegreater the likelihood the patient will experience discomfort, all otherfactors being equal.

According to Lowe (Pages 929-939 in: M H Kryger et al (eds). Principlesand Practice of Sleep Medicine. 3rd edition. Philadelphia: W. B.Saunders Company, 2000.), “dentists early on realized that determiningthe correct jaw position was the most difficult step in using oralappliances successfully” in treating OSDB. In many cases there is atradeoff between efficacy and comfort.

To ease the task of determining the correct jaw position, the dentistmay employ an adjustable MRA, as distinguished from a non-adjustableMRA. According to Schmidt-Nowara et al (Sleep. July 1995;18(6):501-10.),adjustable MRAs allow readjustment of the mandibular position afterinitial construction of the device; for non-adjustable MRAs, suchreadjustments would require refabrication of the entire device.Cartwright (Sleep Med Rev. February 2001;5(1):25-32.), for example,views the lack of adjustability in an oral appliance as disadvantageous.

According to one method of using an adjustable MRA, anteriordisplacement of the mandible is gradually increased (via the MRA) overtime, until the desired therapeutic effect is attained or until patientdiscomfort supervenes. Exemplary adjustment rates include 0.25 mm/night(Ivanhoe and Attanasio. Dent Clin North Am. October 2001;45(4):733-58.),0.5 mm/week (Lowe. Oral Maxillofacial Surg Clin N America.2002;14:305-317.), and 1.5 mm increments (Lowe 2002 supra.). Ivanhoe andAttanasio (supra.) report that, with either a fixed or adjustable MRA,“the initial position of the mandible is generally approximately 70% to75% of maximum protrusion relative to maximum retrusion.” After initialfitting, an adjustable MRA may be configured by repeated assessment toyield the best tradeoff between efficacy and comfort, a processsometimes called “titration.”

A variety of mechanisms, e.g. a screw as used in one MRA known as theKlearway device, or a plunger mechanism as used in the Herbst appliance,have been used to confer adjustability on MRAs. Some mechanisms allowthe patient to make adjustments to the MRA. Other mechanisms are lesslikely to be configured by the patient, and are more commonly adjustedby the dentist. In either case, problems may be associated withadjustable appliances.

For MRAs that are adjusted by the dentist, each adjustment will normallyrequire the patient to bring the MRA to the dentist's office for theadjustment. Such repeated trips may be inconvenient for the patient.

For MRAs that are adjusted by the patient, care must be taken to ensurethe instructions to the patient are clear and correctly understood, andthat the proper adjustment tools, if any, are available. Oversight bythe dentist may also be necessary to detect errors in adjustment by thepatient. For example, if the patient turns the screw of the Klearwaydevice in one direction, the effect will be to advance the mandible; ifturned in the other direction, the effect will be opposite. Furthermore,a special tool is given to the patient to make adjustments in theKlearway; the patient may lose this tool. Lowe (Oral Maxillofacial SurgClin N America. 2002;14:305-317.) cautions that disengaging the toolfrom the Klearway at the wrong time may prevent the patient from fullyengaging the tool at a later time. Some patients with mental impairmentor poor hand-eye skills, perhaps due to poor eyesight or severearthritis, may be unable to adjust the appliance correctly. Thus, it isreasonable to expect that at least some patients tasked to adjust a MRAwill have to be seen in a dentist's office at some point during thetitration process.

Some adjustable appliances have the potential disadvantage of requiringconcentration to make adjustments. For example, an appliance requiringthe turn of a screw cannot be adjusted without attention to the screw,the method of turning the screw, and so forth. This may limit thesituations in which the appliance may be adjusted, and increase thedifficulty that certain classes of patients, may have with theappliance.

Some patients may have to be seen in a dentist's office at theconclusion of the titration process, even when the adjustments have gonesmoothly. Advice on the Klearway device, for example, recommends thatthe dentist “lock in” the configuration of the device once it has beenproperly adjusted, as follows (Lowe. Oral Maxillofacial Surg Clin NAmerica. 2002;14:305-317.): “The expansion screw should be tied off withstainless steel ligature wire or filled in with cold cure acrylic toprevent any further movement of the screw.” An appliance thus locked-inmay no longer be adjustable. Non-adjustability may become undesirablelater, as Ivanhoe and Attanasio (Dent Clin North Am. October2001;45(4):733-58.) caution that “titration may become necessary againat some future time if sleep disorder symptoms recur or tooth ortemporomandibular joint sensitivity appears.”

Another potential disadvantage of adjustable MRAs is their mechanicalcomplexity. Mechanical complexity may cause increased manufacturingexpense and/or increased failure rates. The adjustment mechanism in theKlearway device, for example, appears to be a component that must itselfbe manufactured separately and integrated into the rest of the device.It is also a component that may fail. In 2001 Cartwright (Sleep Med Rev.February 2001;5(1):25-32.) quoted a typical cost of $40-400 for certaintypes of non-adjustable oral appliances used to treat OSDB, and comparedthis to a typical $800-2000 cost for an adjustable MRA.

Thus, it is seen that MRAs may have a variety of potential shortcomings,including being non-adjustable, inconvenient, difficult or confusing forpatients to adjust, relatively failure-prone, and expensive. Adjustableappliances rendered non-adjustable at the completion of titration maynot be able to be used if re-titration becomes necessary or desirable.

From the above, it is desirable to have improved techniques for treatinghealth related disorders.

BRIEF SUMMARY OF THE INVENTION

According to the invention, techniques including a system and method fortreating certain types of breathing problems occurring in a mammalduring sleep and/or other states of diminished consciousness areprovided. More specifically, the invention relates to a system andmethod for stepped treatment of obstructive sleep disordered breathing,using a plurality of oral appliances.

In a specific embodiment, the present invention provides a system fortreating a patient having obstructive sleep disordered breathing, e.g.,sleep apnea. The system has a set of appliances including a firstappliance being adapted to displace a mandible of the patient by a firstpredetermined geometry relative to a maxilla of the patient. The setalso includes at least a second appliance adapted to displace themandible of the patient by a second predetermined geometry relative tothe maxilla of the patient. In a specific embodiment, the firstpredetermined geometry is substantially different from the secondpredetermined geometry. Preferably, either one of the first appliance orat least the second appliance is worn by the patient based upon apredetermined treatment plan that includes one or more provisions forwearing at least the first and the second appliances.

In an alternative specific embodiment, the present invention provides amethod for treating a patient having obstructive sleep disorderedbreathing. The method comprises selecting an appliance from a set ofappliances. The set of appliances is adapted to displace a mandible ofthe patient by a plurality of predetermined geometries relative to amaxilla of the patient, the set of appliances comprising a firstappliance being adapted to displace the mandible by a firstpredetermined geometry relative to the maxilla, at least a secondappliance adapted to displace the mandible by a second predeterminedgeometry relative to the maxilla, and the first predetermined geometryis substantially different from the second predetermined geometry. Themethod further comprises inserting the selected appliance into an oralcavity of the patient, maintaining the selected appliance in the oralcavity during a first time period associated with a first period ofsleep and repeating the selecting, inserting, and maintaining during asecond time period associated with a second period of sleep for eitherthe first appliance or the second appliance based upon if the firstappliance or the second appliance was previously selected, inserted, andmaintained; and a predetermined treatment plan that includes one or moreprovisions for wearing at least the first and the second appliances.

In an alternate specific embodiment the present invention provides amethod for fabricating a set of appliances for treating a patient havingobstructive sleep disordered breathing. The method comprises obtaininginformation associated with a mechanical description of the patient'soral cavity, manufacturing a set of appliances, packaging the set ofappliances, and transmitting the set of appliances to the patient. In aspecific embodiment, the set of appliances is adapted to displace amandible of the patient by a plurality of predetermined geometriesrelative to a maxilla of the patient. The set of appliances comprises afirst appliance being adapted to displace the mandible by a firstpredetermined geometry relative to the maxilla, at least a secondappliance adapted to displace the mandible by a second predeterminedgeometry relative to the maxilla, and the first predetermined geometryis substantially different from the second predetermined geometry. Thetransmitting of the set of appliances includes the first appliance andat least the second appliance.

Various additional objects, features, and advantages of the presentinvention can be more fully appreciated with reference to the detaileddescription and accompanying drawings that follow.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows appliances and appliance indicators according to anembodiment of the present invention.

FIG. 2 shows a portion of an appliance, wherein one indicator isselected from a plurality of possible indicators by virtue of theconfiguration of the appliance, according to an embodiment of thepresent invention.

FIG. 3 shows a flowchart of a portion of a treatment plan according toan embodiment of the present invention.

FIG. 4 shows a flowchart of a portion of an alternative treatment planaccording to an embodiment of the present invention.

FIG. 5 shows a table for deciding what the next treatment should be in atreatment plan according to an embodiment of the present invention.

FIG. 6 shows a method of operation for an assessment means during rapidtitration according to an embodiment of the present invention.

FIG. 7 shows a flowchart of a portion of a re-titration treatment planaccording to an embodiment of the present invention.

DESCRIPTION OF THE SPECIFIC EMBODIMENT

According to the present invention, techniques for treating healthrelated disorders are provided. More particularly, the present inventionprovides improved methods and systems for treating a subset of disordersin which (a) the physical configuration of the upper airway produces, orthreatens to produce, adverse consequences related to respiration, and(b) positioning oral structure(s) such as the mandible and/or tonguelessens or eliminates the adverse consequences. The subset of disordersincludes, but is not limited to, obstructive types of sleep disorderedbreathing (OSDB). Other conditions of diminished consciousness, e.g.coma, stupor, the anesthetic state, and the near-term post-anestheticstate, may also be associated with physical configurations of the upperairway that impede, or threaten to impede, ventilation.

Because a patient who had anesthesia in, for example, 1968, is still,strictly speaking, in a post-anesthetic state today, we use the phrase“near-term post-anesthetic state” to refer to a state of the patientrelatively soon after the administration of anesthesia, during which theanesthetic or its metabolites are having a physiological effect on thepatient.

Obstructive sleep disordered breathing includes conditions such asobstructive sleep apnea (OSA), the upper airway resistance syndrome(UARS), and snoring. Persons having obstructive apneas, obstructivehypopneas, or high resistance breathing (culminating, in classic UARS,in a respiratory effort related arousal) at rates below the diagnosticthreshold for OSA and UARS may also be said to have a type of OSDB.

Continuous positive airway pressure (CPAP) has been reported assuccessful in treating some patients with central sleep apnea (CSA)(Javaheri. Clin Chest Med. 2003;24:207-222.). CPAP is generally known asa treatment for OSDB. Thus, because it appears that at least onetreatment directed at the physical configuration of the upper airway(CPAP) may be helpful in the treatment of CSA, it is reasonable tohypothesize that another such treatment (oral appliances) may alsobenefit some patients with CSA. We therefore note that the presentinvention may find use in the treatment of CSA or in “mixed apnea” (i.e.a combination of CSA and OSDB). For conceptual clarity, we will usuallyrefer to use of the invention in treating only OSDB, but this should notbe taken as a limitation of the invention's possible uses. Furthermore,we consider mixed sleep apnea as a type of OSDB, in which CSA is anadditional characteristic.

Thus, herein we generalize the spectrum of conditions amenable to oralappliance therapy beyond those mentioned by Schmidt-Nowara et al (Sleep.July 1995;18(6):501-10.).

In the present invention, treatment is accomplished with a plurality oforal appliances, each of which may (a) constrain the positions thatcertain oral structures may take with respect to certain other oralstructures in order to achieve a therapeutic effect on a mammalianpatient's airway and/or (b) prepare the patient for subsequent use of anappliance that does a positioning as in (a). For example, in case (b), apatient may not be able to immediately tolerate an appliance that putshis or her mandible into a therapeutic position, and so one or moreappliances without a therapeutic effect on the airway may be worn by thepatient to gradually accustom him or her to increasing mandibulardisplacement, until the therapeutic appliance may be tolerated.

The present invention is not limited to a specific type of appliance.Merely by way of example, the invention provides for appliancesimplemented as mandibular repositioning appliances, as tonguepositioning devices, and as other types of devices. Tongue repositioningdevices reposition the tongue with respect to the mandible (as opposedto MRAs, where the mandible is repositioned with respect to themaxilla).

Merely by way of example, MRAs constrain the positions a patient'smandible may take with respect to the patient's maxilla. By “maxilla,”we also include generally fixed maxillary structures, such as teeth. Wecall the union of all possible mandibular positions allowed by aproperly worn appliance of this type the “geometry” of the appliance.The geometry of other types of appliances, e.g. tongue retainingappliances, may be defined similarly, but with reference to other oralstructures.

Appliance geometries have an abstract shape and location, i.e. they mayoften be conceptualized as a three-dimensional (or less) object locatedin a three-dimensional coordinate space. For an MRA, the coordinatespace is typically referenced to the maxilla or to a neutral position ofthe mandible, and one can generally conceptualize the appliance'sgeometry as the volume of space swept out by a fixed point on themandible as the mandible moves through all possible positions allowed bythe appliance.

Some oral appliances tightly constrain the position of certain oralstructures while others allow movement leeway. For example, an MRA thatdoes not permit any mandibular movement has a geometry approximating asingle point, corresponding to the single position the mandible canassume. By contrast, an MRA that allows some motion of the mandible can,in principle, have a geometry approximating one-, two-, orthree-dimensional shapes, depending on how many degrees of movementfreedom the mandible is permitted. Some MRAs, for example, may allow apatient leeway to open or close their mouth by a limited amount when theappliance is being worn.

Two geometries are equal if their shape and location are the same withina reasonable tolerance, e.g. when the difference between two geometriesis unlikely to have a clinical effect. Thus, for two MRAs a 5-nanometerdifference in one dimension of their geometries is unlikely to haveclinical consequences, whereas differences on the order of a millimetermay be significant in the anterior/posterior direction (but less so inthe open/close direction). Two geometries are different, or, moreformally, “substantially different,” when the difference between themexceeds the reasonable tolerance. Comparing geometries between differentclasses of appliances, e.g. an MRA vs. a tongue-retaining device, ismore complicated.

Adjustable appliances may, by definition, assume a plurality ofconfigurations, though only one at a time. If each configurationconstrains the position of oral structures of interest differently, eachconfiguration of an adjustable appliance will be associated with adifferent geometry. By assuming only one configuration at a time,adjustable appliances are therefore associated with only one geometry ata time. Thus, elements of the present disclosure apply to adjustableappliances as well.

All dimensions or axes of an appliance's geometry may not be equallyimportant. As noted, anterior displacement of the mandible (relative toa neutral mandibular position) figures in the current art related tooral appliances. Because of the importance of the anterior/posterioraxis of appliance geometries, it is often convenient to refer topositions on this axis of an appliance's geometry using the term“anterior displacement.” More generally, “displacement” is, herein, thelength of a vector's projection onto an axis. Although displacement mayrefer to an arbitrary axis and axis-origin, in many cases it refers toanterior displacement from the neutral mandibular position. The verb“displace” has a more general meaning, akin to “position.”

We call a plurality of oral appliances for a single patient a “set” ofappliances herein. The appliances in a set are normally of the sameclass, e.g. MRAs or tongue-retaining devices. Furthermore, when we say aperson wears an appliance and another appliance, the “and” refers tonon-simultaneous wearing of the appliances.

In a preferred embodiment, appliances in a set of appliances aretailored to fit an individual patient, e.g. to fit the patient'sdentition.

The present invention provides that within a set of appliances, thereare at least two different geometries represented. In a preferredembodiment, this plurality of geometries is obtained by a plurality ofnon-adjustable appliances, each fabricated to have a different geometry.For MRA-type appliances, the major difference in geometry between theappliances will often be in the minimum anterior displacement distance.Other embodiments are possible. For example, identical adjustableappliances may be fabricated, and then be configured to have differentgeometries. In another embodiment, a mixture of adjustable andnon-adjustable appliances may be used.

In other words, for a set of N appliances under the present invention,there are at least M geometries represented in the set of appliances,where M and N are both two or more. When non-adjustable appliances areused, M will be less than or equal to N.

In a set of appliances having N>2 appliances, an exemplary embodimentwould include an appliance which displaces the mandible by 75% of itsprotrusive capability, plus a sequence of N-1 appliances that eachdisplace the mandible by some distance D more than the precedingappliance. In one exemplary embodiment, for example, N=6 and D=0.25 mm.

All appliances in a set need not have unique geometries. Duplicateappliances with the same geometry may be desirable as spares or forlogistical reasons (e.g. a patient may keep one appliance at home and aduplicate appliance in a travel kit) or for manufacturing efficiencies.

Appliances within a set of appliances may have other therapeuticproperties in addition to those attributable to their geometry. Forexample, oral appliances have been used to deliver positive airwaypressure during sleep to patients with OSDB (U.S. Pat. Nos. 5,957,133;5,950,624; 5,884,625) and to treat sleep bruxism. There is nothing inthe present invention that precludes the incorporation of suchadditional functions.

In a preferred embodiment, some or all of the appliances in a set ofappliances are used by a patient until an appliance is found whichachieves an acceptable or optimal tradeoff between efficacy anddiscomfort. We call this process titration. In a preferred embodiment,the appliances will initially be used in order of increasing mandibulardisplacement. A further characteristic of titration, which distinguishesit from mere happenstance use of multiple appliances, is that it isembarked upon under the assumption that multiple appliances will betried by the patient under a predetermined treatment plan. We call theappliance that is finally settled upon the “end-titration appliance.”

The invention additionally provides for use after titration. Methodsrelated to the invention are further discussed later.

The present invention also provides a means to identify, withoutmeasuring-tools, appliances in a set of appliances, or aspects of thegeometry associated with the appliances. We call such means an“indicator.” In a preferred embodiment, all appliances in a set ofappliances will be coupled to an indicator and, to the extent theappliances have different geometries, their indicators will differ.

In a preferred embodiment, the indicator is simple for the patient tomentally manipulate. For example, indicators may, but need not, includealphanumeric characters. When alphanumeric characters are used, thefewer the number of characters per indicator, the easier patients willgenerally find it to remember and discuss. It is also preferable thatindicators are easily perceivable by the patient, e.g. if a visualindicator is used, the indicator should preferably be of sufficientsize, visibility, and contrast to allow persons with presbyopia toperceive the indicator and distinguish it from other indicators in theset of appliances without spectacles under typical indoor illumination.Indicators that glow in the dark, or are otherwise perceivable in thedark, may have advantages, since sleep often occurs in a darkenedenvironment.

Certain appliances in a set of appliances may have the same indicator,e.g. when they have the same geometries. In such a case, the indicatorsmay be conceptualized as representing the geometry rather than theappliance itself, and there are situations where such a representationmay be preferable.

This “indicators” feature of the invention appears desirable for manyreasons. For example, it may allow patients and dentists (or otherhealth care personnel) to communicate easily and unambiguously about aparticular appliance or appliance geometry, rather than having to makemeasurements to distinguish appliances. An appliance may be referred toby its indicator, e.g. “appliance X3.” Indicators may also facilitatethe patient's ability to select correctly a desired appliance from aplurality of appliances. For example, a dentist may tell a patient: “Useappliance A for one week, then appliance B for a week, then appliance Cfor a week, then call me.” In this example, the letters A, B, and Cwould be indicators on three different appliances.

In an exemplary embodiment, indicators are standardized between sets,e.g. with a number indicating the tenths of millimeters of anteriormandibular displacement induced by the appliance.

In a preferred embodiment, the indicators for appliances will be orderedto reflect an ordering of the associated geometries. For example, anappliance labeled “#1” might confer the least amount of anteriormandibular displacement, the appliance labeled “#2” might confer thesecond-least amount, etc. Such an assignment of indicators couldfacilitate the use of appliances and make instructions to the patientsimpler. Such an assignment may also find acceptance because it hassimilarities to the concept of dosing well known in pharmacologicalprescribing.

In appliances where mandibular positioning occurs in two different axes(e.g. anterior/posterior and open/closed), indicators may be chosen toreflect displacement in each axis, e.g. indicators consisting of aletter-number pair where the letter reflects anterior/posteriordisplacement and the number reflects open/close displacement. Otherapproaches are possible.

In some situations, e.g. blinded research studies involving oralappliances of the present invention, it may be desirable for anindicator to bear no relationship to the geometry of its correspondingappliance.

Non-geometric characteristics of an appliance may be reflected in itsindicator.

Indicators may be coupled with appliances in a variety of ways,including, but not limited to, permanent embossing of an alphanumericcode 122 onto an appliance 121, as shown in FIG. 1-B; color-coding anappliance or portion of an appliance; having the indicator on a tag 112that is removably attached to the appliance 111, as shown in FIG. 1-A;embedding the indicator within the appliance; and so on.

In some embodiments, an indicator may arise at least in part from theconfiguration of the appliance. For example, FIG. 2 shows a portion ofan exemplary appliance that could also provide an indicator function.The portion of the exemplary MRA schematically represented in FIG. 2consists of an upper portion 210 and a lower portion 220, correspondingto appliance portions that abut a patient's upper and lower teeth,respectively. The upper portion has a male protrusion 230 and the lowerportion has a plurality of numbered female receptacles 240. Indicatornumbers 250 are coupled to the appliance such that they each correspondto a female receptacle. The configuration of the appliance (and,therefore, its geometry) is determined, in part, by which of the femalereceptacles 240 the male protrusion 230 is inserted. When the maleportion is inserted in any of the female receptacles, it is possible fora human to readily ascertain, by inspection, the corresponding indicatornumber 250 which may then be incorporated in an indicator for thatconfiguration of the appliance. Thus, in this example, the indicatorarises at least in part from the mechanical characteristics of theappliance, out of a plurality of possible indicator numbers coupled tothe appliance.

In a specific embodiment, an indicator is palpable. For example, apalpable, “tongue-readable” indicator may allow a patient to determinethe particular appliance (or appliance geometry) that he or she iscurrently wearing without removing the appliance from the mouth. FIG.1-C shows an appliance 131 with three protrusions 132 amenable toperception by palpation with the tongue posterior to the position of theincisor teeth. Various physical arrangements (e.g. horizontal, vertical,diagonal, triangular, etc.) and numbers of such protrusions could serveas indicators.

Indicators may also be configured such that they are recognizable byelectronic hardware or other artificial means. Elements of an electronicidentification-and-data-capture system are an example of an indicatorthat could be recognized by artificial means. A radio frequencyidentification (RFID) tag with an identifier code is a possible elementof such a system. For example, an RFID tag could be incorporated intoeach appliance in a set of appliances, with the tag containinginformation describing the appliance.

There is nothing in the invention to exclude an indicator that isrecognizable both by humans and by artificial means, or by a human inconcert with artificial means. Nor is there anything in the invention toexclude a plurality of indicators on a particular appliance. When anappliance has a plurality of indicators, some may be recognizable byhumans and some may not, and some may be recognizable by artificialmeans and some may not.

Indicators that are recognized by an artificial recognition means mayhave advantages in several situations. A patient may be incapable of, orinaccurate in, recognizing indicators, e.g. a patient with dementia. Anartificial recognition means could provide a data recording, monitoring,or notification means with a reference to an indicator, so that amessage could be passed to the patient or caregiver if an improperappliance were being worn. In research settings it may be desirable tohave an artificial recognition means identify appliances, while leavingthe subject unaware of indicators and appliance identity.

In an exemplary embodiment, an artificial recognition means is coupledto a means for assessing sleep breathing. For example, a portion of theartificial recognition means could occupy the same housing occupied by apre-tracheal sensor functioning in the diagnostic assessment of sleepbreathing (see, for example, U.S. patent application Ser. No.10/721115). In an exemplary embodiment, an artificial recognition meansin such a housing is an RFID reader that obtains information from anRFID tag in the appliance in the patient's mouth. In an exemplaryembodiment, an artificial recognition means is additionally programmedwith a treatment plan, or communicates with some component having accessto the treatment plan, thereby permitting the correctness (according tothe treatment plan) of the worn appliance to be determined and,possibly, communicated to a notification component.

Once fabricated, a set of appliances will normally need to betransmitted to a patient. Once the patient has the appliances, they willnormally need to be stored when not being worn. In both cases, placingone or more appliances within one or more enclosures may be convenient.An enclosure may be, but is not limited to, a box or a sac. Theenclosure may be mailable, which is to say it can be coupled to awritten shipping address (or code) and it can be packed with one or moreappliances in such a way that the appliance(s) are not at unreasonablerisk of damage from the physical forces associated with shipping. Anenclosure may be reclosable.

Other components of the invention may be usefully coupled to theenclosure, including, but not limited to, instructions-for-use, elementsof the treatment plan, appliance indicator(s), means to facilitate useof appliances (e.g. a calendrical means), or a means to assess use ofthe invention (e.g. a diary means or an electronic use-assessment means,which could also be coupled to appliances).

In some embodiments, the enclosure may serve other purposes. Forexample, an enclosure may also form part of a means to clean one or moreappliances, e.g. by supplying a container to hold liquid cleaning agent,into which one or more appliances are placed to soak.

Appliances from a set of appliances are typically worn one at a timeduring periods of time associated with sleep periods. Thus, during thedaytime, a patient generally does not wear an appliance unless sleep isplanned. In some cases, however, it may be helpful for the patient towear orthodontic aligners (e.g. those described in U.S. Pat. Nos.5,975,893 and 6,554,611) during wakefulness to counteract any tendencyof the oral appliances to move teeth during sleep. Tooth movement(leading to occlusal change) is generally an undesirable possible sideeffect of oral appliance therapy for OSDB (Ferguson. Clin ChestMedicine. 2003;24:355-364.). Patients may be instructed to performcertain jaw motions or jaw exercises to reduce other effects of thesleep appliances.

In a preferred embodiment, a patient would be provided with a set ofappliances and a treatment plan guiding the use of the appliances. In anexemplary embodiment, the treatment plan is in a readable form,including, but not limited to a hardcopy form (e.g. printed) or anelectronic form (e.g. as viewed on a computer monitor or personaldigital assistant). The treatment plan may refer to two or moreappliances in the set of appliances provided to the patient. Thetreatment plan may refer to an appliance by referring to an indicatorcoupled to the appliance. The patient may also be provided withinstructions-for-use that may or may not be in the same form as thetreatment plan. The treatment plan may be provided to the patient'scaretaker or other interested party.

Herein we distinguish a treatment plan from instructions-for-use.Instructions-for-use teach the use of a single appliance, e.g. “put theappliance in your mouth,” or “keep the appliance clean.” A treatmentplan makes reference to the sequential use of a plurality of appliances.Instructions given to a patient may include elements ofinstructions-for-use, elements of a treatment plan, or both.

A variety of treatment plans are possible including, but not limited to,titration with one set of appliances, titration with two or more sets ofappliances, and long-term use. Persons familiar with the art willunderstand that additional or alternative classes of treatment plans arepossible. A treatment plan may be altered, even after treatment hasbegun.

In a preferred embodiment, titration of oral appliances for thetreatment of OSDB uses information about the degree of OSDB that ispresent in the patient at various times and under various conditions. Itis seen, therefore, that a convenient and accurate means of assessingOSDB is desirable.

OSDB may be assessed in several ways. It may be assessed by a patient,e.g. according to the degree of OSDB symptoms or sleep quality thepatient experiences. OSDB may be assessed by observers, e.g. thepatient's bed-partner who hears some degree of snoring or witnessesapneas. OSDB may be assessed by artificial means, such aspolysomnography, oximetry, and those described in U.S. Pat. Nos.5,671,733; 5,782,240; 5,879,313; 5,961,447; 6,045,514; 4,982,738;5,275,159; 6,120,441; 6,290,654; 6,213,955; 6,171,258; 5,797,852;6,142,950; 6,306,088; 6,319,205; 6,322,515; and U.S. patent applicationSer. No. 040937, for example. Combinations of techniques may be used.Measurement of respiratory rate, body movement, and/or oronasal air flowmay be useful in some cases. Other methods are possible. As noted above,an artificial means for assessing OSDB may be coupled to an artificialmeans for recognizing appliance indicators.

In an exemplary embodiment, titration precedes a phase of (stable)long-term use of appliance(s) having a single geometry. Titration maygenerally be conceptualized as a process to correlate a plurality ofappliance geometries with: assessments of discomfort, or one or morefeatures of the patient's OSDB, or both. With this correlation in hand,a decision about the geometry of a long-term appliance (if any) can bemade rationally.

In an exemplary embodiment of a titration using a set of appliances, theN appliances in the set are ranked from 1 to N, according to the minimummandibular displacement induced by each appliance, and the rank numberis the indicator for each appliance. For simplicity, we assume theappliances in the set displace the mandible in a uniform direction;appliances with more complicated displacements may require morecomplicated ranking functions. Thus, appliance 1 corresponds to theappliance associated with the least mandibular displacement andappliance N corresponds to the appliance associated with the greatestmandibular displacement. In such an embodiment, an exemplary treatmentplan would direct that the patient wear appliance 1 until some endpointis reached, then wear appliance 2 until some endpoint is reached, and,assuming N≧3, so on for appliances 3 to N or until titration wascompleted.

FIG. 3 is a flowchart for an exemplary titration treatment plan.Titration begins 310 with a patient selecting the initial appliance froma set of N appliances referenced by the treatment plan, where theappliances are ranked and indicated by mandibular displacement asdescribed above. This selected appliance is now the “current appliance,”or, synonymously, “appliance M,” where M is an integer from 1 to N,inclusive. After the patient wears the current appliance (step 320), anoptional assessment (step 330) is made of the effects of wearing theappliance. This assessment could include the degree of discomfortassociated with wearing the current appliance, the therapeuticeffectiveness of wearing the current appliance (as determined, forexample, from assessing OSDB severity during wear of the appliance), andso on. The assessment may be made after each night of wear, after somelarger number of nights of wear, or even after less than a night's wear(e.g. a test wearing). The treatment plan may specify the interval forsuch assessments, but it in many cases the patient will make at least aninformal assessment after each wearing.

After wearing the current appliance (step 320), a decision 340 can bemade whether to continue titration. This decision can be based on anumber of factors, including but not limited to the effects of wearingthe current appliance as determined in step 330, the availability of anappliance with a greater mandibular displacement, and the like.

In the event titration is continued, it can be asked (step 350) whetherthe current appliance (appliance M) should continue to be worn, orwhether an appliance with the next greater degree of mandibulardisplacement (appliance M+1) should be worn. This decision 350 can bebased, for example, on the number of nights that appliance M has beenworn, the degree of patient discomfort associated with wearing applianceM, the number of discomfort-free nights the patient has had wearingappliance M, and so on. If the decision 350 is to continue wearing thecurrent appliance, then the cycle repeats (starting with step 320) whenthe patient next wears the current appliance. If the decision 350 is toswitch to appliance M+1 (i.e. the appliance with the next greater degreeof mandibular advancement than the current appliance), then applianceM+1 is designated the current appliance, as indicated by the incrementin M in step 360. The cycle then repeats (starting with step 320), withthe newly designated current appliance.

As noted above, a variety of factors could be used to decide that thetitration phase should be ended. For example, intractable patientdiscomfort with appliance M could precipitate the end of the titrationphase, based on a decision that continued attempts to use appliance Mare not warranted and that appliances with greater degrees of mandibulardisplacement (i.e. appliances M+1 to N, where M<N) are likely to also beassociated with unacceptable levels of discomfort. As a further example,it may be determined that appliance M achieves the desired therapeuticeffect, and there is therefore no need to try other appliances. As afurther example, all appliances, 1 to N, in the set of appliances mayhave been repeatedly worn by the patient, with the result that there areno appliances in the set of appliances left to try. In such a situation,a treatment failure may be declared (see below).

At the end of the titration phase, the end-titration appliance isdetermined 370. One possible heuristic to guide the selection might be:“Pick the appliance that (a) has the smallest degree of mandibulardisplacement achieving the desired therapeutic effect, and (b) iswell-tolerated by the patient.” As an example, consider a situationwhere the titration showed that appliance M lowered the patient'sapnea-hypopnea index (AHI) to 2/hr but was associated with significantpatient discomfort, while appliance M−1 (i.e. the appliance with thegreatest mandibular displacement that is less than the mandibulardisplacement of appliance M) lowered the patient's apnea-hypopnea indexto 3/hr and was well-tolerated by the patient. If the desirabletherapeutic effect in this example is to lower the patient's AHI to lessthan 5/hr, then appliance M−1 may be chosen as the end-titrationappliance, because it achieved that and was well-tolerated by thepatient.

In cases where an adequate therapeutic effect is not achieved with anyof the appliances that the patient can tolerate, a treatment failure maybe declared (not shown in FIG. 3). In such a situation a new set ofappliances may be ordered and titration initiated with the newappliances. Such a re-titration is most likely to be effective if thenew appliances have different geometries than the original set ofappliances, or if the new appliances differ in some other significantway from the appliances in the original set of appliances, e.g. the newappliances lack a specific feature that in the original appliances wascausing discomfort to the patient.

An exemplary titration treatment plan (co-mingled withinstructions-for-use) given to the patient might be: “A goal oftreatment is to find an oral appliance that is both comfortable to wearand effectively treats your sleep breathing problem. You have been givena set of oral appliances. The appliances are numbered 1 through 5. Youwill wear an appliance each night when you sleep. You will choose whichappliance to wear based on the schedule below. Whichever appliance youwear, put it in your mouth before you go to bed, and remove it from yourmouth when you get up to start your day. You should wear your appliancesaccording to the following schedule: Appliance #1: Wear it each nightfor a month. Appliance #2: Wear it each night for two weeks. Appliance#3: Wear it each night for two weeks. Appliance #4: Wear it each nightfor two weeks. Appliance #5: Wear it each night for a week, thentelephone your dentist. The appliances are built to be comfortable towear, and the schedule is built to give you time to get used to each ofthe appliances. Despite this, some appliances may be uncomfortable.Discomfort usually decreases over time, but if an appliance isuncomfortable after two consecutive nights of wear, call your dentist.If an appliance causes bleeding, remove the appliance and call yourdentist the next morning.”

In the example treatment plan above, time is the predominant factordetermining when a change is made from one appliance to another.Although a precise time was used in the example, a time range, e.g. “oneto two weeks,” may also be used. As noted earlier, other factors may beused to determine when to change from one appliance to another; thesefactors may be reflected in the treatment plan. Such factors include,but are not limited to: (1) the presence or degree of adverseconsequences of appliance wear (e.g. discomfort, bleeding, gingival orother dental effects), (2) assessment(s) of the patient's breathing(e.g. subjective assessments such as a bedpartner's perception ofsnoring by the patient, or objective assessments of the patient'sbreathing during sleep), or (3) assessment(s) of consequences ofsleep-disordered breathing in the patient (e.g. assessment of symptom(s)and/or sign(s) of sleep-disordered breathing, including hypertension,heart failure, nocturia, cognitive effects, and the like), or (4)assessment(s) of whether the patient has been using the appliances inproper accord with the treatment plan.

The treatment plan may be formulated to maximize simplicity. In theexample above, 3 of the 5 appliances are scheduled to be worn for twoweeks during the titration phase. The schedule could be simplified bymaking all wear-periods the same. Dentists and other health careprofessionals will likely appreciate this flexibility in patients withlimited self-care abilities, in whom overall treatment success mayresult more from patient understanding and compliance than from optimalscheduling.

In a preferred embodiment, the treatment plan is presented to thepatient before beginning wear of an appliance from the set ofappliances. The treatment plan may include adjuncts, such as a calendarto remind or assist the patient in determining which appliance should beworn on a particular date. The calendar may be annotated with referencesto a specific appliance, to a specific action (e.g. “Call your dentist'soffice today and give a progress report”), to decisions, to questions,and the like. In cases where the patient needs assistance with care, thecalendar may be given to a relative, a friend, or other caretaker. Thecalendar may be paper-based or electronic, e.g. implemented on apersonal digital assistant. The calendar may be generated by a human orby a computer or other device.

In an alternative embodiment, the specifics of a treatment plan may bepresented to a patient over time. For example, after awakening eachmorning during the titration process, the patient could call a telephoneinteractive response system, and be prompted to enter information aboutrecent appliance use, e.g. the current appliance's indicator, the degreeof discomfort associated with wearing the appliance, the degree of OSDBsymptoms, the bed-partner's report of snoring, etc. The response systemcould use an algorithm of arbitrary complexity, possibly tailored to theindividual patient and appliance set, to determine the next treatment(s)to be used in the treatment plan. The patient could then be so informedon the telephone, or later. Thus, when the treatment plan itself may betoo complicated to present fully to the patient, instructions on how toaccess an interface to the treatment plan may be given instead.

FIG. 4 shows a flowchart for a possible treatment plan in which multipletreatment steps (450, 460, 470, 480) are possible after an assessment430 of the effect of wearing an oral appliance. The treatment planbegins by selecting an appliance M₀ from a set of appliances for thepatient to wear initially (step 410). As in FIG. 3, the currently wornappliance is referred to as appliance M (420). In this embodiment, theassessment 430 has been structured to provide information along twoaxes: effectiveness and comfort of appliance M. Given the larger numberof possible treatment steps in this embodiment, the step of deciding ona particular treatment step (440) may be relatively complicated (seeFIG. 5 and discussion below). Possible treatment steps include endingtitration successfully 450 or declaring a treatment failure 460 with thecurrent set of oral appliances. Another possible treatment step 470 isto add or change a treatment modality other than oral appliances, forexample, instituting positional therapy with a tennis ball sewn to thepatient's pajama top, using a Breathe-Right(R) strip to improve nasalairflow, using a medication to suppress rapid-eye movement sleep, etc.Another possible treatment step is to select a different appliance towear 480, one that might have a greater mandibular displacement than thecurrent appliance (e.g. “M←M+1”) or one having less mandibulardisplacement than the current appliance (e.g. “M←M−1”). There may becases in which performing more than one treatment step after anassessment 430 may be advisable.

FIG. 5 shows an exemplary embodiment of deciding on a treatment step(akin to step 440). In this embodiment, the decision is based on twoinputs: the degree of discomfort associated with wearing appliance M,and the degree of effectiveness with which appliance M treats thepatient's sleep breathing problem. The degree of discomfort is describedas 0 (no discomfort), 1 (tolerable discomfort), or 2 (intolerablediscomfort). The degree of effectiveness is described as 0 (noteffective), 1 (marginally effective), 2 (mostly effective), or 3(completely effective). For a given level of discomfort andeffectiveness for a given oral appliance M, FIG. 5 shows whattreatment(s) to perform next. It can be seen that the decision table issufficiently complex, and the inputs sufficiently simple, that anadjunct such as the interactive telephone system mentioned above may bebeneficial.

A predetermined treatment plan referencing a plurality of appliances ispresent in several embodiments of the present invention. A predeterminedtreatment plan can be helpful by setting the patient's expectationsappropriately, enhancing control of the clinical process, enhancing therange of appliance treatment options, and permitting certainmanufacturing and logistical efficiencies.

Titration of oral appliance therapy for OSDB, when performed outside ofa sleep laboratory, generally proceeds over days and weeks in thecurrent art. Features of the present invention, however, could enablemore rapid titration, e.g. in one night in some cases.

For titration to occur in one night, it follows that adjustments to thepatient's oral appliance(s) may need to be made during the night. It iswell known that some persons encounter difficulty concentratingimmediately after being awakened from sleep. Thus, patients who havejust been awakened from sleep may find it difficult to concentrate tothe degree required to adjust an appliance in the existing art, sinceconcentration is needed for some adjustment procedures.

A feature of the present invention, however, is that changes inmandibular positioning may be accomplished in many cases withoutdemanding significant concentration from the patient. For example, toincrease the amount of mandibular displacement during an awakening froma sleep period, the patient need only remove the current appliance fromhis or her mouth, and select and insert a different appliance having agreater displacement. It is seen that this sequence of steps requiresrelatively little concentration from the patient, suggesting that manypatients will be able to perform multiple titration steps during theperiod of time associated with a sleep period, albeit an interruptedsleep period. Demands on the patient may be further reduced by devicesthat prompt the patient on what action to take, e.g. “Insert appliance#3.”

In a preferred embodiment, the titration process includes a monitoringmeans coupled to a notification means. The monitoring means may, forexample, collect and act upon data related to OSDB severeity in apatient. The notification means alerts the patient to various situationsat various times. Because the patient may have been sleeping orattempting to sleep at such times, a notification means may use one ormore methods of capturing the patient's attention, including, but notlimited to, delivering (or causing to deliver) a noise to the patient, ashock to the patient, a vibration to the patient, combinations of theabove, and so on. The patient's bed-partner or caretaker may be notifiedin some cases.

FIG. 6 summarizes a preferred embodiment for operation of the monitoringmeans. The monitoring means is first configured with a plurality ofoperating parameters 610, e.g. element(s) of a treatment plan,descriptors of the set of appliances used by the patient, criteria fornotifying the patient of certain events, and the like. A variety ofother parameters may be loaded, e.g. the name of the patient.

Monitoring of patient-related physiological and environmental data 620may begin automatically (e.g. at a predetermined time or upon detectionof a certain set of circumstances such as appliance wear) or with inputfrom the patient (e.g. pressing a button). In an exemplary embodiment,the monitoring means is able to recognize an indicator of the applianceworn by the patient. After reading the indicator, the monitoring meansmay determine 640 whether the appliance being worn is the appliance thatshould be worn, according to the operating parameters loaded in step610. If the correct appliance is not being worn, the monitoring meansformulates a message 680 for the patient, then passes a specification ofthe message to the notification means 695 (see below). The message maybe symbolic, e.g. illumination of a certain light emitting diode;textual, e.g. the string “wrong appliance;” etc.

If the correct appliance is being worn, or if the monitoring means doesnot have the capability to determine the indicator being worn,processing of incoming data may begin 650. Assuming the monitoring meanshas not been deactivated 660 (e.g. deactivating by pressing an “off”button), a determination is made 670, after an appropriate amount ofdata have been processed, as to whether the data meet criteria fornotifying the patient. For example, a reasonable notification criterionmight be: “if the patient has had more than 5 apneas or hypopneas in thepreceding 60 minutes, notify the patient to switch to the next appliancespecified by the treatment plan.” The corresponding message that mightbe delivered to the patient in such a situation might be “Change toappliance #4.” After formulation of the message to be delivered to thepatient 690, the message specification for the message is passed to thenotification means 695 for delivery to the patient.

It is seen from the description above that the monitoring means, in apreferred embodiment, should be capable of determining the presence orabsence of OSDB in near-real time, so that notification messages may begenerated and delivered promptly. It may, therefore, incorporate a meansto assess OSDB.

In a preferred embodiment the monitoring means has access to informationabout the position of the patient's body (with respect to gravity) atsubstantially the same time it has access to information about thedynamics of the patient's ventilation. Body-position information isoften valuable in this context because the effectiveness of an oralappliance may vary according to body position. For example, in somecases, OSDB is more severe when a patient is sleeping in the supineposition. When assessments of OSDB are performed over relatively shortperiods of time (e.g. less than several hours during a night's sleep),it may be important to know that a patient has not yet slept in thesupine position (for example) with a particular appliance. In such anexample, the appliance may not yet be considered “acceptable” unless ithas been used by the patient over a period of time in the position whereOSDB is generally the most severe. Thus, not only may it be helpful tohave the monitoring means determine when OSDB is still present, it mayalso be helpful to have the monitoring means determine that sufficientdata have been collected to reasonably exclude the presence of OSDB.(Similar considerations may apply to certain sleep stages.)

Thus, in an exemplary embodiment, the patient sleeps with a sensor forthe assessment of OSDB that detects both tracheal sound and bodyposition (as described in U.S. patent application Ser. No. 10/721115).It will be apparent to those skilled in the art that otherinstrumentation arrangements for the assessment of sleep breathing arepossible, examples of which were noted earlier.

In a preferred embodiment, the notification means 695 is an audiospeaker. The messages formulated in steps 680, 690, or elsewhere maytherefore be output so the patient can hear them. Text-to-speechsoftware, known to persons skilled in the art, may be used to facilitatethe output. Various techniques to get the patient's attention, such asrepeating messages at louder volumes, or vocalizing the patient's firstname, may be employed. In many cases it will be desirable for theinvention to have a means for the patient to stop notification.Alternatively, the monitoring means may detect a change in conditions(e.g. the patient is now wearing a different appliance) and ceasenotification as a result. After notification ceases, control may revertto the monitoring means, for example at step 630.

Repeated assessments, notifications, and appliances may enable a patientto perform several titration step changes during a night (or otherperiod of time associated with a sleep period). In some cases, a patientmay be able to complete titration in one night.

One plausible method to minimize the expense associated with the presentinvention is to minimize the number of appliances fabricated anddelivered to the patient. Too few appliances, however, may haveundesirable consequences. For example, displacements may be spaced toofar apart, so that one appliance is sub-therapeutic and the appliancewith the next-greatest degree of displacement is uncomfortable. Analternative approach to minimizing the number of appliances is tofabricate and deliver them as needed, but there is expense associatedwith such an approach as well.

A middle ground is to use two sets of appliances, wherein the appliancesin the first set have displacements that are spaced relatively widelyand the appliances in the second set have displacements that are spacedrelatively narrowly. The patient's ideal displacement may beapproximated by the first set of appliances, and more preciselydetermined afterwards with the second set of appliances. The second setof appliances is fabricated to have displacements in a range derivedfrom those appliances from the first set that worked the best with thepatient.

In an exemplary embodiment, titration with the first set would identifytwo appliances, one being sub-therapeutic but comfortable and the othertherapeutic but uncomfortable. The second set of appliances could thenbe fabricated, with displacements in this second set spaced between thedisplacements of the two appliances identified in the first set, anddelivered to the patient. Titration with the second set of appliances(possibly including the two appliances identified from the first set aswell) would then determine the long-term appliance geometry for thepatient.

A second set of appliances would not be necessary if an appliance in thefirst set were both therapeutic and comfortable.

Ivanhoe and Attanasio (Dent Clin North Am. October 2001;45(4):733-58.)note that success often accompanies empirically choosing an appliancewith a displacement of 70-75% of the maximum mandibular protrusion apatient can obtain relative to maximum retrusion. Thus, it seemsreasonable for the initial set of appliances to have detaileddisplacement resolution at or near this amount. The intervals betweendisplacements in a set of appliances need not be identical.

The present invention could be used in association with an adjustableappliance, wherein the adjustable appliance substitutes in function forthe first set of appliances. In this embodiment, the adjustableappliance need not be durable, since it will be used only for the shortperiod of time it takes to complete the initial titration.

In some cases it may be preferable to deliver a small number ofappliances separately to the patient over time, rather than in largesets. For example, FIG. 5 includes a treatment step in which the patientis asked to wear a tolerably uncomfortable appliance for a week beforewearing a different appliance. Should a treatment plan include one ormore situations in which there is advance warning that a certainappliance is required, it would be possible to defer manufacture and/orshipping of the certain appliance until the patient has progressed to apoint in the treatment plan where it is certain (or above someprobability threshold) that the appliance will be needed. Manufacture ofappliances at different times is more likely to be economically feasibleif the manufacturing occurs from the same initial mechanical descriptionof the patient's oral structures.

Once an end-titration appliance has been chosen, this appliance maythereafter be recommended for chronic nighttime (i.e. sleep-time) use bythe patient. Alternatively, a geometry associated with the end-titrationappliance may be used to fabricate a “long-term” appliance with asimilar geometry but having different non-geometric features.

For example, the appliances used in titration might be made less durablein order to reduce cost. In such a case, once the end-titrationappliance is determined, a higher cost, more durable appliance havingthe same geometry as the end-titration appliance can be fabricated forlong-term use by the patient.

A long-term appliance having no change in geometry over time will likelybe adequate to manage some patients with OSDB. However, the clinicalstate of some patients will change over time. Such a change may alterthe effectiveness of a given appliance geometry over time.

For example, some patients may gain weight or become hypothyroid. Overgenerally shorter periods of time, a patient may imbibe alcoholicbeverages, may become partially sleep deprived, may begin taking certainmedications, or may develop nasal congestion. All of these factors, andothers as well, may unfavorably influence OSDB in some patients,rendering treatment with the long-term appliance less effective.

Conversely, weight loss, treatment of hypothyroidism, lessening ofalcohol or cigarette use, or discontinuation of certain medications(e.g. certain sedatives) may occur. These factors, as well as others,may favorably influence OSDB in some patients, rendering treatment withthe long-term appliance excessive.

Issues related to comfort with a long-term appliance may arise, e.g. ifa patient develops dysfunction of a temporomandibular joint.

Thus, it is seen that various events may re-initiate the search for anappliance (or appliance geometry) best suited for the patient, a processwe call “re-titration.” A plurality of treatment plans are possible forre-titration; FIG. 7 shows an example. FIG. 7 assumes the patient hasbeen wearing an appliance M (710). (This is not required for allre-titrations, e.g. the patient may be non-compliant with appliancetherapy).

In cases where an alteration in clinical state or an alteration inappliance effectiveness is suspected, it may be desirable to assess thedegree of OSDB using an assessment means, with the decision to pursuere-titration dependent, at least in part, on the results. In some othercases, just the suspicion of a change 720 may be sufficient to initiatere-titration. In yet other cases, assessments of OSDB may be performedin a surveillance mode, i.e. without specific cause, in order to detectchanges in effectiveness of the long-term appliance that might otherwiseescape notice.

In cases where improvement of OSDB is suspected or documented, it may bereasonable to attempt down-titration, i.e. a lesser degree of mandibulardisplacement may be required than previously as in steps 730 and 750. Insome situations, patients may be able to dispense with oral appliancetherapy. In cases where worsening of OSDB is suspected or documented, itmay be reasonable to attempt up-titration as in steps 730 and 740. In apreferred embodiment, a change in the appliance worn leads to assessmentof airway function and adverse effects of the appliance 760, followed bya decision 770 on whether the patient's clinical state is acceptablewith the new appliance.

As mentioned, some factors influencing OSDB may occur relativelyacutely. In such cases, deviation from the long-term appliance may bebeneficial. For example, if a patient has consumed alcohol, he or shemay wish, on that night, to use an appliance imparting greatermandibular displacement than the long-term appliance. This is an examplewhere the appliance worn is changed without an assessment. Such a changemay be based on past experience (in which assessments were made afterconsuming alcohol) or based on a knowledge base (correlating alcoholintake with OSDB severity). In some cases a patient's bed-partner maynotice (or be disturbed by) uncharacteristic snoring from the patient,despite the patient wearing the long-term appliance. The patient may beprompted to awaken and insert an appliance with a greater displacement.

In an embodiment of the present invention, a full set of appliances ismanufactured and transmitted to a patient in one shipment. This approachmay be associated with manufacturing and shipping efficiencies. In analternate embodiment, all appliances in a set of appliances may not betransmitted to the patient in one shipment, e.g. one or more appliancesof a set of appliances, coupled with a treatment plan that refers to twoor more of the appliances in the set, may be transmitted in oneshipment, with other appliances to follow. In this embodiment thetreatment plan possibly mentions or alludes to a fact that the two ormore appliances have different geometries (although not necessarily inthose words). Shipping less than the full set of appliances may incurlower overall costs if the cost of manufacturing appliances is high orif closer control of the patient's appliance use is desired.

When appliances are tailored to a patient's dentition, information aboutthe mechanical structure of the patient's dentition is normally receivedby one or more entities involved in the fabrication of the appliances.This information often includes a description of the shape of the teethand a description of the relative position between mandible and maxilla.Additional information, e.g. the maximal protrusion of the mandible, theextent of the gums, or information related to the desired geometries ofthe appliances may also be included.

Such mechanical information may be captured by taking a casting(sometimes called “an impression”) of the patient's dentition.Appliances may then be constructed on the basis of the casting.Alternatively, appliances could be tailored to a patient by having thepatient perform a “tailoring maneuver,” e.g. incorporating a deformablematerial into an appliance and having the patient bite down on thedeformable material in order to provide a custom fit to the patient'sdentition. Such materials are known to persons with ordinary skill inthe art, including materials that are deformable only under certainconditions, e.g. elevated temperatures.

Alternatively, appliances may be tailored to fit an individual patientby using information obtained during a scan of the patient's oral cavityand associated structures. For example, information collected duringmagnetic resonance imaging or other imaging of the head may be used todevelop a three-dimensional representation of the patient's dentition ina computer memory, and appliances may be fabricated on the basis of thatrepresentation. Other imaging modalities (e.g. computerized tomographicX-ray imaging) are known to persons with ordinary skill in the art.

When a casting is made, the cast may be physically transmitted to themanufacturer. In general, however, electronic communication will oftenbe more rapid than such physical transmissions. Thus, there may beadvantages associated with transmitting mechanical informationelectronically, e.g. from one computer memory to another.

In some cases, the mechanical information provided to the manufacturermay be incomplete or inadequate. For example, an appliance may need tobe modified (“re-worked”) in order to give the patient a comfortablefit, e.g. if information about the extent of the gums, relative to theteeth, is not provided and an appliance is fabricated that painfullyimpinges on the gum. When an appliance is transmitted to the patient, itwould appear desirable to minimize the amount of re-work it might laterneed.

One approach to minimizing re-work is to obtain initially as complete adescription of the patient's oral cavity as practical and possible.

Another approach is to make a first appliance for a patient based onmechanical information obtained, then test-fit the appliance in thepatient, then communicate descriptions of any necessary rework back tothe manufacturer for incorporation into future appliances for thepatient.

An exemplary embodiment of this approach is a computer station in whichthe dentist indicates, with light pen, graphics tablet, mouse, or other2-dimensional or 3-dimensional input device, the location and nature ofrework required on an appliance to obtain a satisfactory fit for apatient. The computer then transmits this rework information to themanufacturer, where the information is merged with pre-existingmechanical information concerning the patient's oral cavity and/orprevious appliance(s). Subsequently, appliance(s) may be manufacturedfor the patient with the rework modifications already present, reducingthe odds that rework of the same type would be needed on the newlymanufactured appliances.

In an exemplary embodiment, an oral appliance that has been subjected torework is placed in a computer-connected apparatus that allows3-dimensional localization of points in space. A dentist may indicate aparticular point (or region) of the appliance with an input device, andsupply the computer with information about rework performed in thevicinity of the point or region. The rework information may be enteredon a computer keyboard or with other computer input devices familiar tothose with knowledge of the art.

In such an embodiment, it would be desirable for the coordinates of thepoint (or region) to be expressed according to a frame of reference thatcould be applied to the appliance as well. A common frame of referencewould allow localization of the point (or region) with respect to theappliance. For example, a 3-d scanner could determine the shape of theappliance and its surface boundaries in an arbitrary frame of reference,and the indicated point (or region) could be expressed in the same frameof reference; other approaches are possible. Certain markings orstructures on or in the appliance may serve as the basis forestablishing a coordinate system.

In a preferred embodiment, a reworked appliance is 3-dimensionallyscanned by a computer-connected apparatus, providing a digitalrepresentation of at least the appliance's shape. The digitalrepresentation of the reworked appliance is compared to a digitalrepresentation of the appliance before rework (again requiring one ormore common reference frames), allowing the reworking to be identified,isolated, and represented digitally. The reworking would then be appliedto subsequently manufactured appliance(s).

Alternatively, the representation of a reworked appliance could itselfbe used as a basis for manufacturing subsequent appliance(s), withoutidentifying, isolating, or representing the rework specifically.

It is seen, therefore, that there are advantages to keeping informationabout a patient's oral cavity in a digital system, as it will besimpler, in most cases, to consolidate newly-gained information witholder information, as compared to a mold or casting.

Certain efficiencies under the invention may result when appliances aremanufactured synchronously. In an exemplary embodiment, a plurality oforal appliances, wherein at least two of them have substantiallydifferent geometries, may be said to be manufactured synchronously whenany of: (a) they are manufactured close together in time, e.g. less than48 hours, (b) there was no feedback to the manufacturing process betweenthe time of a first appliance's fabrication and the time of a secondappliance's fabrication that altered the planned geometry of the secondappliance, or (c) they are transmitted to the patient, unused,simultaneously or in a common enclosure or in a common shipment.Additional embodiments of synchronous manufacture are possible, andthere is a similar embodiment for a configurable appliance (i.e. anappliance whose geometry is determined, at least in part, by one or moreconfiguration steps), if the words “configuration” and “configured”replace “manufacture” and “manufactured” in the embodiment justdisclosed. In some cases, the appliances may have been tailored to thepatient substantially before the configuration step(s).

The present invention has many potential advantages. When a plurality ofmechanically simple, e.g. non-adjustable, appliances is used per thepresent invention, both the mechanical complexity and the manufacturingexpense may be lowered compared with adjustable appliances. Yet,advantages usually associated with adjustability would still beavailable to patient and dentist (and possibly other health careprofessionals), by virtue of the different geometries represented by theplurality of simple appliances. Additionally, the present invention neednot employ special tools or parts to adjust appliances.

A further advantage associated with using inexpensive appliances in thepresent invention is logistical flexibility for patients. For example, apatient can, for a relatively low cost, order multiple copies of theend-titration appliance, e.g. he or she can keep one appliance at homenext to the bed, pack another appliance in his or her travel kit, keepanother appliance at a relative's house that is frequently visited, andkeep another appliance as a spare.

A further advantage of the present invention is the potentially smalleramount of time required for a dentist to manage a patient's carecompared to other methods of oral appliance therapy. For example,patients need not return to the dentist's office to have an applianceadjusted; instead, adjusting a patient's mandibular position using thepresent invention can be done over the telephone with a simple sentencesuch as “Switch from appliance #2 to appliance #3.” As a furtherexample, using non-adjustable appliances in the present invention meansthat, in principle, there will be no need for a patient to visit adentist upon completion of titration in order to have an appliance“locked in” to a final position. Yet, the dentist does not sacrificeflexibility, because of the plurality of appliances available for him orher to treat the patient.

Another advantage of the present invention is the potential simplicityof instructions that a patient will need upon initiating treatment.Examples of possible instructions have already been given. Suchinstructions are often simpler than instructing the patient on themechanics of adjusting an adjustable appliance, or having the patientcome in for office visits during the titration process. Indeed,instructions for use of the present invention can approach thesimplicity of pharmacological titration instructions. For example, aphysician might instruct a medicine-taking patient as follows: “Take onepill a day for two weeks, then two pills a day for two weeks.” A similarinstruction given to a patient that could apply to the present inventionmight be: “Wear appliance #1 at night for two weeks, then appliance #2for two weeks.”

Using the present invention, even relatively complicated portions oftreatment plans may be described with simple patient instructions, e.g.“Wear each appliance for two weeks after your discomfort with itvanishes, then advance to the next appliance in sequence and repeat” or,after brief coaching on pain scales, “Wear each appliance for two weeksafter your discomfort with it drops to 3-out-of-10 or less, then advanceto the next appliance in sequence and repeat.”

There are other potential advantages. Because the time needed from adentist may be reduced and because instructions to patients are largelyfree of the need for detailed dental knowledge, once the oral appliancesof the present invention are delivered to a patient, it becomesreasonable for a non-dentist physician to manage the patient's oralappliance therapy. (Most physicians, of course, are not dentists.) Insuch a case, attention might be needed from the dentist only inanomalous situations and for routine long-term follow-up of thepatient's dentition and oral health.

A novel feature of the present invention is that it potentially brings asimple and reliable dosing method to oral appliance therapy for OSDB.The importance of dosing is illustrated by the familiar model of dosingin the pharmacological treatment of hypertension: if the blood pressureof a patient being treated for hypertension rises to undesirable levels,the dose of the patient's anti-hypertensive medication can often beincreased to bring the blood pressure back to desirable levels. Thepresent invention allows a similar “dose” adjustment, where “dose”derives from appliance geometry. If a patient under treatment for OSDBdevelops, for example, new symptoms or signs of OSDB, the patient can beinstructed to try an appliance providing greater mandibular displacementthan the appliance the patient is currently wearing.

Similar advantages carry into situations where the proper “dose” ofmandibular displacement might change more rapidly, for example, afteralcohol consumption, when sleep deprived, during a transient illness,etc.

It should be noted that the above sequence of steps is merelyillustrative. Any of the above steps can also be separated or becombined, depending upon the embodiment. In some cases, the steps canalso be changed in order without limiting the scope of the inventionclaimed herein. One of ordinary skill in the art would recognize manyother variations, modifications, and alternatives. It is also understoodthat the examples and embodiments described herein are for illustrativepurposes only and that various modifications or changes in light thereofwill be suggested to persons skilled in the art and are to be includedwithin the spirit and purview of this document.

1. A system for treating a patient having obstructive sleep disorderedbreathing, the system comprising: a set of appliances comprising: afirst appliance being adapted to displace a mandible of the patient by afirst predetermined geometry relative to a maxilla of the patient; atleast a second appliance being adapted to displace the mandible of thepatient by a second predetermined geometry relative to the maxilla ofthe patient; whereupon the first predetermined geometry is substantiallydifferent from the second predetermined geometry; whereupon either oneof the first appliance or at least the second appliance is worn by thepatient based upon a predetermined treatment plan that includes one ormore provisions for wearing at least the first and the secondappliances.
 2. The system of claim 1 wherein the set of appliancesfurther comprises one or more additional appliances, each of theappliances in the set being adapted to displace the mandible of thepatient by a predetermined geometry relative to the maxilla of thepatient, where the predetermined geometry for each appliance in the setof appliances is different from the predetermined geometries of theother appliances in the set of appliances.
 3. The system of claim 1wherein the treatment plan is readable.
 4. The system of claim 1 whereinthe obstructive sleep disordered breathing is obstructive sleep apnea.5. The system of claim 1 wherein the set of appliances is packed in asingle enclosure to encase at least the first appliance and the secondappliance for transmission to the patient.
 6. The system of claim 1further comprising: a first indicator coupled to the first appliance; asecond indicator coupled to the second appliance; whereupon the firstindicator and the second indicator provide a respective first visualfeature and a second visual feature to allow the patient to visuallydistinguish the first appliance from the second appliance.
 7. The systemof claim 6 wherein the first indicator and the second indicator are eachcomposed of 4 or fewer substantially contiguous alphanumeric charactersat least 3 mm in height.
 8. The system of claim 1 wherein the first andsecond appliance are tailored to the patient's dentition.
 9. A methodfor treating a patient having obstructive sleep disordered breathing,the method comprising: selecting one of a plurality of appliances from aset of appliances, the set of appliances being adapted to displace amandible of the patient by a plurality of predetermined geometriesrelative to a maxilla of the patient, the set of appliances comprising afirst appliance being adapted to displace the mandible by a firstpredetermined geometry relative to the maxilla, at least a secondappliance adapted to displace the mandible by a second predeterminedgeometry relative to the maxilla, and the first predetermined geometryis substantially different from the second predetermined geometry;inserting the selected appliance from the set of appliances into an oralcavity of the patient; maintaining the selected appliance in the oralcavity during a first time period associated with a first period ofsleep; and repeating the selecting, inserting, and maintaining during asecond time period associated with a second period of sleep for eitherthe first appliance or the second appliance based upon if the firstappliance or the second appliance was previously selected, inserted, andmaintained; and a predetermined treatment plan that includes one or moreprovisions for wearing at least the first and the second appliances. 10.The method of claim 9 wherein the treatment plan is readable.
 11. Themethod of claim 9 wherein the repeating of the selecting, inserting, andmaintaining depends on an assessment of the discomfort experienced bythe patient in maintaining the selected appliance.
 12. The method ofclaim 9 wherein the repeating of the selecting, inserting, andmaintaining depends on an assessment of the breathing of the patientduring at least the first time period.
 13. The method of claim 12wherein the time between the inserting and the repeating of theselecting, inserting, and maintaining is less than 48 hours; theselecting selects the first appliance; and the repeating of theselecting, inserting, and maintaining selects the second appliance. 14.A method for fabricating a set of appliances for treating a patienthaving obstructive sleep disordered breathing, the method comprising:obtaining information associated with a mechanical description of thepatient's oral cavity; manufacturing, based on the informationassociated with the mechanical description, a set of appliances beingadapted to displace a mandible of the patient by a plurality ofpredetermined geometries relative to a maxilla of the patient, the setof appliances comprising a first appliance being adapted to displace themandible by a first predetermined geometry relative to the maxilla, atleast a second appliance adapted to displace the mandible by a secondpredetermined geometry relative to the maxilla, and the firstpredetermined geometry is substantially different from the secondpredetermined geometry; packaging the set of appliances; andtransmitting the set of appliances including the first appliance and atleast the second appliance to the patient.
 15. The method of claim 14wherein manufacturing of the first appliance and manufacturing of atleast the second appliance occur within 48 hours of each other.
 16. Themethod of claim 14 wherein no additional information associated with themechanical description of the patient's oral cavity is obtained betweenthe manufacturing of the first appliance and the manufacturing of atleast the second appliance.
 17. The method of claim 14 wherein the setof appliances is packaged within a single enclosure.
 18. The method ofclaim 14, wherein the information associated with a mechanicaldescription of the patient's oral cavity is obtained at a first locationwhere the manufacturing is not performed, and is sent to at least asecond location where the manufacturing is performed.
 19. The method ofclaim 18 wherein the sending occurs electronically.
 20. The method ofclaim 18 wherein no additional information associated with themechanical description of the patient's oral cavity is sent between themanufacturing of the first appliance and the manufacturing of at leastthe second appliance.